- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.53 / $1,456.62 / $1,688.01
| Professional | | $1,243.53 | $1,456.62 | $1,688.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,023.97 / $5,434.88 / $6,434.26
| Facility | | $4,023.97 | $5,434.88 | $6,434.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.34 / $1,495.70 / $2,501.44
| Professional | | $1,271.34 | $1,495.70 | $2,501.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.24 / $1,769.38 / $1,769.38
| Facility | | $1,646.24 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $1,769.38
| Professional | | $1,291.65 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.32 / $1,625.37 / $2,366.46
| Professional | | $1,283.32 | $1,625.37 | $2,366.46 |